Dilated Left Coronary Artery Research Articles

Pediatric coronary cameral fistula in a structurally normal heart: a case report and review of the literature

IntroductionCoronary cameral fistulas (CCFs) are rare congenital anomalies characterized by abnormal connections between a coronary artery and one of the cardiac chambers. These abnormal connections can lead to significant clinical implications, including heart failure and myocardial ischemia, necessitating timely diagnosis and intervention.Case presentationA 5-year-old Iranian boy was brought to the emergency room at Heart Hospital Center complaining of chest pain and dyspnea on exertion. He had experienced similar episodes over the past 4 months, which had not been evaluated. Physical examination revealed stable vital signs and no remarkable findings. Transthoracic echocardiography demonstrated a dilated left coronary artery with a large aneurysm and a small orifice to the right ventricular body. The left ventricular ejection fraction was 55%. Cardiac computed tomography angiography confirmed the diagnosis. Cardiac angiography showed a dilated left coronary artery and a coronary cameral fistula to the right ventricular . The aneurysm was successfully occluded using two Amplatzer™ devices.ConclusionThis case underscores the critical role of multimodal imaging in diagnosing and managing coronary cameral fistulae. Early detection and appropriate intervention are paramount in preventing the progression of symptoms and potential complications such as heart failure and myocardial ischemia. The successful closure with Amplatzer™ devices highlights the efficacy of minimally invasive techniques in treating complex cardiovascular anomalies. Regular follow-up and careful monitoring are essential to ensure long-term success and to manage any potential recurrences.Clinical key messageTimely identification and management of coronary cameral fistulae are crucial to prevent complications. Advances in imaging techniques and minimally invasive treatments, such as transcatheter closure, offer effective solutions. A multidisciplinary approach and regular follow-up are essential for comprehensive care and successful long-term management.

Atypical Kawasaki disease presenting with macroscopic hematuria in an infant: a case report

BackgroundKawasaki disease is an acute febrile condition in children. It affects mainly children under 5 years old, and is known to cause coronary artery abnormalities if treatment is delayed. The diagnosis rests mainly on clinical criteria. However, it is also known that some infants do not have diagnostic criteria sufficient enough for the diagnosis of Kawasaki disease. Further, children may rarely present with unusual features, and this entity is recognized as “Atypical Kawasaki disease.”Case presentationWe present the case of a 9-month-old Tamil boy who presented with sterile gross hematuria in association with prolonged fever, lymphadenopathy, and generalized maculopapular rash. He had high inflammatory markers and echocardiogram disclosed left coronary artery dilatation. The diagnosis of incomplete Kawasaki disease was confirmed based on clinical grounds supported by investigations and exclusion of differential diagnosis. The child showed a good response to intravenous immunoglobulin and aspirin.ConclusionKawasaki disease is one of the important differential diagnoses of protracted fever of unknown origin in very young children. Since delayed treatment is associated with a high risk of complications, atypical Kawasaki disease needs to be suspected in children presenting with unusual features such as macroscopic hematuria that occurs in association with unexplained prolonged fever.

The challenges of multisystem inflammatory syndrome diagnosis and treatment

A two-year-old girl with fever, diarrhea and vomiting was presented to the Emergency Department (ED). A maculopapular rash on the face, cervical lymphadenopathy and 1st degree dehydration were being noted. Laboratory results showed leukocytosis, neutrophilia and a high level of C-reactive protein (CRP). Amoxicillin was prescribed, but the patient’s state did not improve. She returned to ED with rash all over her body and 2nd degree dehydration. Laboratory results revealed thrombocytopenia and a more increased level of CRP. It was found that her mother has been diagnosed with the coronavirus disease approximately two months ago. Extended laboratory results showed signs of mild anemia, increased levels of liver enzymes, procalcitonin, troponin, N-terminal prohormone of brain natriuretic peptide, D-dimers, ferritin. Anti-SARS-CoV-2 (severe acute respiratory syndrome-coronavirus) IgG (immunoglobulin G) were detected. Multisystem inflammatory syndrome was diagnosed. Pediatric echocardiography revealed 10 mm of fluids in pericardium, I degree mitral valve regurgitation, dilated left coronary artery. She was given a treatment with intravenous Immunoglobulin G, methylprednisolone and aspirin, but her state did not improve. A treatment with Tocilizumab was given, but it did not have a much more positive effect, laboratory results showed progressed leucocytosis and neutrophilia. As the last resort, biology treatment with a recombinant form of human interleukin-1 receptor antagonist Anakinra was started and after a week all symptoms changed, and laboratory results regressed.

Circumflex Coronary Artery Fistulae Draining into Right Atrium: A Case Report

Coronary artery fistula (CAF) is an anomaly making a coronary artery communicate with a heart cavity or a great vessel, thus bypassing the myocardial capillary bed. CAF is frequently diagnosed as an incidental finding. Herein, we present the case of a 4-year-old boy. He was referred for a pediatric cardiology assessment due to a continuous murmur at the middle sternal border. Echocardiogram showed dilated left coronary artery and an abnormal diastolic flow in the right atrium. The right-sided chambers were slightly enlarged, but ventricular contractility was normal. CAF was suspected. Angiography and CT confirmed the diagnosis of coronary fistula from the circumflex coronary artery to the right atrium. Successful transcatheter closure with an Amplatzer PiccoloOccluder was performed with complete occlusion.

Anomalous origin of the left coronary artery from the pulmonary artery as a rare cause of mitral valve prolapse: a case report

Background Mitral valve prolapse (MVP) is an etiologically heterogeneous disorder. Early diagnosis and prompt treatment of the underlying disease are of great significance. Herein, we present a rare case of MVP caused by anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA).Case presentationA 22-year-old female presented with a 16-year history of anterior mitral leaflet prolapse. However, she had never experienced any discomfort before. At a routine follow-up, a transthoracic echocardiogram showed anterior mitral leaflet prolapse (A2) with moderate mitral regurgitation, and a retrograde blood flow from an extremely dilated left coronary artery (LCA). Further coronary angiography and coronary computed tomography angiography confirmed the diagnosis of ALCAPA. She subsequently underwent successful LCA reimplantation and concomitant mitral valve replacement. Intraoperatively, her mitral annulus was mildly dilated, anterior mitral valve leaflet appeared markedly thickened with rolled edges, and a chordae tendineae connecting the anterior leaflet (A2) was ruptured and markedly shortened.ConclusionsALCAPA is a rare and potentially life-threatening congenital coronary artery anomaly that may cause mitral valve prolapse. Echocardiogram is an important screening tool for this disorder.

Pediatric-onset systemic lupus erythematosus with coronary artery dilation

Introduction:Though pediatric-onset systemic lupus erythematosus (SLE) is at high risk of coronary artery involvement, coronary artery dilation appears to be a rare characteristic of pediatric-onset SLE. In this article, we described 1 pediatric-onset SLE patient with coronary artery dilation at the diagnosis of SLE, in order to better diagnose and manage this cardiac complication of SLE in children.Patient concerns:A 13-year-old boy was admitted in hospital for daily fevers with the highest temperature of 39.2°C over 10 days, with rash, non-exudative conjunctivitis, cervical adenopathy, knee, and ankle arthralgi. The result of echocardiogram implicated coronary artery dilation and aortic regurgitation. Further laboratory tests showed: Coomb's test (+), decreased C3 complement. The results of immunologic tests were only to find ANA (+) with titer 1:3200, ds-DNA (+).Diagnosis:This patient was diagnosed as SLE complicated with coronary artery dilation.Interventions:The patient was treated with intravenous methylprednisolone pulse therapy. He was discharged home on prednisone maintain treatment.Outcomes:As soon as treatment, his temperature returned to normal, with recovery of rash, conjunctivitis, knee, and ankle arthralgi. However, the echocardiogram of this patient after 3 months also had dilation of left coronary artery (LCA) and right coronary artery (RCA).Conclusions: Cardiac complication can occur during the entire course of SLE, suggesting that routine echocardiogram surveillance may be necessary for all SLE patients to prevent morbidity and mortality from cardiovascular events.

649 Anomalous Right Coronary Artery From the Pulmonary Artery (ARCAPA): An Unusual Cause for a Murmur

A 6 year old girl was referred to our service after an incidental murmur was heard during a GP review for prominent neck veins when she was upset. She had a grade 1-2/6 soft systolic murmur at the left sternal edge. She was clinically asymptomatic and had good exercise tolerance. Chest X-ray was unremarkable and a 12 lead ECG showed deep Q waves in the inferolateral leads. An echocardiogram showed a significantly dilated left coronary artery (LCA) with multiple collaterals in the interventricular septum. The right coronary artery (RCA) was seen to arise from the pulmonary artery as shown in Figure 1. There was normal biventricular systolic function with no regional wall motion abnormalities. A cardiac CT confirmed that the RCA arose from the anterior and right-ward aspect of the pulmonary artery as shown in Figure 2. The LAD was dilated and tortuous, supplying the RCA via the posterior descending artery.Figure 2View Large Image Figure ViewerDownload Hi-res image Download (PPT) ARCAPA is an extremely rare anomaly, estimated to occur in 0.002% of the general population. It often presents asymptomatically with massive collateralisation between the normal and anomalous coronary artery required to maintain adequate myocardial perfusion. ARCAPA is associated with structural heart defects in a third of cases, where it tends to be diagnosed earlier. Reimplantation is the treatment of choice but surgical ligation of the RCA with saphenous grafts have also been described.

Transcatheter occlusion of giant congenital coronary cameral fistulae: a case series

BackgroundA coronary cameral fistula is a rare connection between a coronary artery and a cardiac chamber or vein bypassing the cardiac capillary bed system. Most of these fistulae are congenital and solitary, although they can be acquired and multiple.Cases presentationCase 1: A 10-year-old black South African boy presented with a long-standing history of fatigue; he had a heart murmur, and a bounding pulse and wide pulse pressure. An echocardiogram demonstrated a large coronary cameral fistula involving his left coronary artery and his left ventricle. This was also confirmed on ascending aortogram. Surgical ligation was done and his symptoms improved afterward, but a small residual fistula remained. Case 2: A 7-year-old black South African boy had decreased effort tolerance and a heart murmur on the mid-sternal border. He had cardiomegaly on chest roentgenogram and a dilated left coronary artery origin on echocardiogram. An ascending aortogram confirmed a large left coronary cameral fistula draining to the left ventricle. Case 3: A 28-year-old black South African woman with decreased effort tolerance and chest pain on exertion had a continuous murmur over the lower sternal border. Echocardiography demonstrated a dilated right coronary artery with a fistulous connection to her right ventricle. An ascending aortogram demonstrated a tortuous coronary cameral fistula arising from her right coronary artery to her right ventricle. All three patients were successfully treated percutaneously using the Amplatzer vascular plug type II device.ConclusionThe availability of numerous vascular closure devices has made transcatheter occlusion the treatment of choice for the majority of coronary cameral fistulae, rather than the traditional surgical ligation.

Coronary artery aneurism in Kawasaki disease: Case series and literature review

Kawasaki disease (KD) is associated with coronary artery lesion, especially in the form of aneurysm and ectasia. The first case is 1-year, 9-month-old female; the second is a 13-month-old male, the third is a 14-month-old female, and the fourth is a 5-year, 6-month-old male who all satisfied the criteria of KD. Echocardiography done for all the series showed dilatation of the left anterior descending coronary artery measuring 2.15 mm with Z score of 2.53 and focal dilatation of left main coronary artery with maximum diameter of 2.9 mm with Z score of 2.44 for the first case, prominent left coronary artery measuring 2.19 mm with Z score of 1.28 with borderline dilatation of the circumflex coronary artery measuring 2 mm with a Z score of 2.13 for the second case, and left coronary dilatation measuring 3.5 mm with Z score of 3.61 and borderline left coronary artery dilatation measuring 3.5 mm with a Z score of 2.24, respectively, for the last two cases. We documented four cases of KD as much as we know, and all the four cases presented with coronary artery aneurism with a good response to chemotherapy.

Kawasaki disease: a confusing trigger in hemophagocytic lymphohystiocitosis

Results A 4 year-old boy was hospitalized to investigate a fever of unknown origin. At day 24 of persistent fever, he presented rash and left coronary artery dilatation (3.6mm) were detected, and was diagnosed with atypical KD. He received high-dose immunoglobulin (IVIG, 2g/Kg, in 3 days) but fever had persisted and coronary dilatation worsened (left coronary artery 4.2mm and anterior descending artery 2.8mm and circumflex artery 2.6mm). At day 33 he presented severe clinical deterioration and fulfilled diagnostic criteria for HLH. As KD was considered the HLH trigger, a modified protocol for treatment was applied. He was treated with IVIG and dexamethasone (initial dose 10mg/m2/day) with remission of the fever after the first dose and progressive clinical and laboratorial improvement. Due to the persistence of splenomegaly, thrombocytopenia and neutropenia, he received one dose of etoposide at day 48 with resolution of the cytopenias. Clinical and laboratory parameters improved to normal levels, coronary arteries dilatation reduced (left coronary artery 2.2mm, anterior descending artery 2.0 mm and circumflex artery 1.6mm), allowing progressive reduction of the corticosteroid. Splenomegaly is the only abnormality that still persists after 40 days of treatment.

Invasive tests in pregnancy

The letter to the editor “Safety concerns in pregnancy”, written by Yalcinkaya et al. (1), was very interesting, questioning the real benefits of performing invasive tests during pregnancy. In particular, regarding the case report entitled “Congenital aneurysmal circumflex coronary artery fistula in a pregnant woman” (2), written by our group, the authors considered no benefit and suggested there may even be a potentially harmful effect associated with performing a hemodynamic study during pregnancy for the evaluation of an asymptomatic coronary fistula. From our point of view, in this specific case, it was important to perform a hemodynamic study because the echocardiogram was not completely conclusive for the diagnosis of a coronary fistula and because there was a substantial risk of a differential diagnosis of anomalous origin of the coronary arteries (3). In the presented case, the echocardiogram showed a markedly dilated left coronary artery, which could indicate anomalous origin of the right coronary artery. It is known that anomalous origin of a coronary artery can induce ischemic events in both a mother and her fetus at the end of pregnancy and during the delivery period (4). Therefore, it was imperative to definitively discard the possibility of that harmful condition. An invasive hemodynamic exam is still considered as the gold standard method to investigate coronary fistulas and anomalous origin of a coronary artery and can be performed with a very low risk to either the mother or fetus when the recommended precautions are observed, including appropriate abdominal lead coverage for the mother and minimized fluoroscopy time (5). Fortunately, in the case that we presented, cardiac catheterization confirmed the diagnosis of a coronary fistula, enabling clinical management throughout the time remaining until the delivery.

Coronary artery abnormalities in children with systemic-onset juvenile idiopathic arthritis

Still's disease (Systemic-onset Juvenile Idiopathic Arthritis: SoJIA) is characterised by high-spiking daily fevers, arthritis and evanescent rashes. Diagnosis of Still's disease is often challenging. Infectious diseases and other inflammatory conditions, especially in young children, Kawasaki disease may look similar. Clinicians often rely on echocardiographic evidence of coronary artery abnormalities to differentiate between Kawasaki disease and Still's disease. Coronary artery dilation would typically favour the diagnosis of Kawasaki disease. We present four children with Still's disease and coronary artery abnormalities who were initially misdiagnosed as Kawasaki disease. The first patient had pericarditis and an irregular wall of the left coronary artery, without dilation on echocardiography. The second patient had a left coronary artery dilatation and a pericarditis. The third patient had thickened left coronary artery walls, and the fourth patient had a hyperechogenicity of the left and right coronary arteries. They received IVIG without success. The diagnosis of Still's disease was made secondary with evidence of persistent arthritis. All but one patient finally needed biologic treatments. Coronary abnormalities may be observed during various febrile conditions and do not exclude the diagnosis of Still's disease.

Unusual manifestations of Kawasaki disease with retropharyngeal edema and shock syndrome in a Taiwanese child

We report a 3-year-old girl with Kawasaki disease who presented with retropharyngeal edema and shock syndrome. This is the first reported case in Taiwan. The patient initially presented with fever, cough, and pyuria followed by rapidly progressive enlarged bilateral cervical lymphadenopathy. On the third day of the fever, computed tomography for airway compression sign found widening of the retropharyngeal space mimicking a retropharyngeal abscess. Later, an endotracheal tube was inserted for respiratory distress. A skin rash over her trunk was also noted. On the fifth day of the fever, the clinical course progressed to hypotension and shock syndrome. Because of more swelling of bilateral neck lymph nodes, computed tomography was arranged again and revealed partial resolution of the edematous changes in the retropharyngeal space. Edema of the hands and feet, bilateral bulbar conjunctivitis, and fissured lips were subsequently found. The diagnosis of Kawasaki disease was confirmed on the eighth day of fever. There was no evidence of bacterial infection. She was administered intravenous immunoglobulin (2mg/kg) and high dose aspirin (100mg/kg/day). One day later, the fever subsided, and her blood pressure gradually became stable. Heart echocardiography on the Day 13 revealed dilated left coronary artery and mitral regurgitation. Follow-up echocardiography six months later showed normal coronary arteries. To date, the patient has not experienced any complications. This case illustrates that retropharyngeal edema and shock syndrome can be present in the same clinical course of Kawasaki disease. Clinicians and those who work in intensive care units should be aware of unusual presentations of Kawasaki disease to decrease rates of cardiovascular complications.

OP-036 TRANSCATHETER CLOSURE OF CORONARY ARTERY FISTULAS

Objective: Coronary artery fistulas (CAF) are rare congenital or acquired malformations in which a direct vascular connection from a coronary artery to a cardiac chamber or a great vessel, bypassing the myocardial capillary network exists. Large fistulas may cause heart failure, myocardial ischemia, arrhythmias, endocarditis, potential aneurismal dilatation and rupture; and require closure, if symptomatic, upon recognition. METHODS and Results: Patients evaluated in our clinic with murmur, heart failure, history of infective endocarditis or suspected cardiac anomaly who were diagnosed with CAVF and cardiac catheterization was performed are included in this study. Between 2003 and 2009, 12 patients aged between 3 days and 204 months (median 42 months) were diagnosed with coronary artery fistulas and transcatheter closure of CAVF was accomplished in nine patients, whereas it was not possible to close the fistula in three patients. In the nine patients that TCC could be achieved, the fistula originated from the left coronary artery in six patients and from the right coronary artery in three; and ended in right side of the heart in seven and left side in two. A narrowing in the distal segment of the fistula was observed in almost all of the patients, and the diameter of this narrow segment was between 1-5 millimeters. The fistula was closed retrogradely in seven and anterogradely in two. Multiple microcoils, vascular plugs, PFM coils, fibrin glue and ADO II were used during the procedure. Control angiography was performed in eight patients. Seven patients had complete occlusion; one had further aneurismatic dilatation of left coronary artery and a residual shunt, and was referred to surgery. Patients were followed up for 13 -48 months (median 35 months) during which time no device related complication was observed and patients presented with heart failure showed significant improvement. Conclusions: Coronary artery fistulas can be safely and effectively closed using transcather techniques. Anatomical variations and different sizes of coronary artery fistulas necessitates availability of different sizes and types of devices at the time of catheterization for successful closure. Patients need to be closely followed up for complication such as residual shunts, new fistula formation and coronary artery stenosis.

Giant Coronary Aneurysms Caused by Kawasaki Disease

An 8-year-old boy who presented to our hospital had all of the signs consistent with Kawasaki disease (KD; i.e., all criteria were met). He was treated with intravenous gamma globulins and oral acetylsalicylic acid. Transthoracic echocardiography showed a dilated left coronary artery (LCA) that was 15 mm in diameter. His platelet count was increased at 1.2 million/mm. The patient was well when he was discharged to home. There was no change in his echocardiogram on discharge. During the 6-month followup period, the child had no cardiac symptoms. A routine follow-up coronary angiography showed an 18 mm–wide coronary artery aneurysm (CAA) in the LCA. A few smaller aneurysms in the distal part of the left circumflex artery were also noticed (Fig. 1). The right coronary artery (RCA) was completely blocked (Fig. 2). Contrast medium, however, was visible distally in the RCA due to collateral flow. Discussion

Coronary Arteriovenous Fistula: Direct Connection of the Proximal Circumflex Artery to the Coronary Sinus

To the Editors, We have read with great interest the article by Jeewa and colleagues published in Pediatric Cardiology describing two cases of coronary arteriovenous fistula [1]. The authors reported that the dilated left coronary artery communicated directly with the coronary sinus. The abnormal vessel ran along the atrioventricular groove and entered into the right atrium through a restrictive Thebesian valve. The morphology and location of this dilated vessel suggested the direct connection of the proximal circumflex artery to the coronary sinus. We recently experienced a case quite similar to these cases. A 12-year-old girl was referred to our hospital for a continuous murmur. The echocardiography had shown an appearance similar to that of the reported cases. The aortography also showed that the dilated left circumflex artery appeared to connect with the enlarged coronary sinus (Fig. 1a, b). However, the multidetector-row computed tomography (MDCT) images showed that the coronary sinus was present next to this abnormal vessel (Fig. 1c, d). This dilated vessel originated from left coronary artery and drained directly to the right atrium. We considered that this abnormal vessel could not be the coronary sinus in either our case or Jeewa’s cases. If the vessel was the coronary sinus, the coronary perfusion would not be workable because the blood pressure in the coronary sinus can be much higher than in the peripheral coronary arterial branches. It was quite difficult to distinguish the coronary sinus from the abnormal dilated vessel draining into the right atrium using echocardiography or conventional angiography. Although fistulas between the circumflex coronary artery and the coronary sinus are rare [2], it is quite important and essential to make a precise diagnosis. In these cases, MDCT is a promising tool for precise depiction and determination of the optimal treatment.

Widened Coronary Arteries in a Feverish Child

A 3-year-old girl with fever of unknown origin after a visit to Surinam was seen at our hospital. Signs and symptoms were indicative of either Kawasaki syndrome or an acute viral or (atypical) bacterial illness. No cardiac abnormalities were noted at echocardiography. She was treated with intravenous immunoglobulin and clarithromycin and made a quick recovery. Serologically, the diagnosis of murine typhus was made; a flea-borne rickettsiosis caused by Rickettsia typhi. A follow-up echocardiography 1 week later showed a dilated left coronary artery, which was normal again 4 weeks later. We suggest that this phenomenon was a manifestation of rickettsial vasculitis.

Atypical Kawasaki Disease Presenting as Intestinal Pseudo-obstruction

Intestinal pseudo-obstruction in atypical Kawasaki disease (KD) is rare. A boy aged 2 years and 6 months presented with a 7-day history of fever, coffee-ground vomit, and abdominal pain. Abdominal radiography and ultrasound showed a dilated duodenum. Peeling of the skin on his fingers and toes developed on hospitalization day 9. Echocardiogram revealed right and left coronary artery dilatation compatible with KD. He was treated with 2 g/kg intravenous immunoglobulin (IVIG), with rapid resolution of fever and relief of abdominal pain. Follow-up abdominal radiography and ultrasound showed improvement of bowel dilatation. This case illustrates that atypical KD can present with intestinal pseudo-obstruction. A high index of suspicion is required for early diagnosis, and prompt treatment with IVIG is recommended.

Transesophageal echocardiography for the diagnosis of coronary arteriovenous fistula

A9-year-old asymptomatic boy had a continuous murmur, loudest in the right parasternal region. Physical examination and electrocardiogram were normal. Transthoracic echocardiography showed a turbulent color flow into the right atrium. There was right ventricular dilatation. TEE showed a dilated left coronary artery from the left sinus. The left anterior descending and circumflex arteries were normal. Near the crux, the circumflex branch gave off a large branch. This was a coronary arteriovenous fistula whose entire course was traced to its drainage into right atrium (Fig. 1). It started near the crux, passed a little anterior and then turned posterior and slightly superior. It was 11 mm at the origin. It passed in the posterior atrioventricular groove and turned anterior again before its termination. Finally, its drainage into the posterolateral aspect of right atrium was visualized. It was slightly bulbous prior to its emptying into the right atrium. Selective angiography (Fig. 2) showed normal (but dilated) left main, normal left anterior descending and circumflex arteries. Left anterior descending artery followed its normal course. The fistula arose form the circumflex

Factors predicting mortality in patients after myocardial infarction caused by left main coronary artery occlusion: significance of ST segment elevation in both aVR and aVL leads.

Acute left main coronary artery obstruction is rare and most patients in this clinical setting die of sudden death or cardiogenic shock. During the past 8 years, we encountered 13 patients with acute myocardial infarction caused by total occlusion of the left main coronary artery (LMCA-AMI). Thus, we surveyed these patients, and attempted to elucidate helpful predictors related to the prognosis. Six of 13 patients with LMCA-AMI survived. Successful left coronary artery dilatation was achieved in all survivors (group S), and in 5 (71%) non-survivors (group non-S). The age was not different between the two groups. A past history of angina was confirmed in 83% of group S. while only in 29% of group non-S. Clinical findings such as time of onset of AMI, interval from the AMI onset to admission, elapsed period from the AMI onset to recanalization of LMCA and the value of CK on admission were not different between the two groups. However, cardiogenic shock occurred in only 1 patient (17%) in group S compared with 5 patients (71%) in group non-S. As emphasized in the literature, good collateral circulation to the left anterior descending artery was observed in 5 patients (83%) in group S, while not observed in group non-S. Electro cardiographically, ST elevation in the aVR lead was very characteristic. This finding was confirmed in 69% of the total patients. Noticeably, 5 out of 6 non-survivors (83%) showed ST elevation not only in leads aVR but also in the aVL lead. In addition to the absence of collateral circulation, this electrocardiographic finding, which obviously indicates the presence of extensive myocardial ischemia in the diseased heart, is a simple and important predictor suggesting a poor prognosis in LMCA-AMI patients.